Dear Plastic Surgery Applicant:

Thank you for your interest in becoming an Operation Smile Plastic Surgery Volunteer! As you know, Operation
Smile relies on volunteers to give their time and expertise to help bring smiles to the faces of children at home and
around the world.
Enclosed you will find a volunteer application. To help expedite the application process, please submit the
completed application along with:
Current Curriculum Vitae/Resume
Copies of diplomas and degrees (Both medical degree and Specialty training)
Current Board certification or equivalent (Certification or membership of an Accrediting Institution
for your specialty)
Current license (document providing legal authorization to practice, often issued by a national or
provincial Health Department)
Copy of your passport
Please do not send incomplete application packages. Both the Application and CV must be completed in
English. Upon receipt of your complete application packet, it will be forwarded to the Plastic and Reconstructive
Surgery Council for review. The Plastic and Reconstructive Surgery Council may telephone you to clarify
information and determines the recommendation status of the application. This process can take up to 8 weeks.
Operation Smile will inform you of the results of your application. Upon approval by the Plastic and
Reconstructive Surgery Council, an applicant will be entered into the Operation Smile Medical Volunteer
database, indicating eligibility to participate on a medical mission. Mission selection guidelines state that all
mission teams be comprised of at least 50 percent experienced Operation Smile team members and the remainder
of the team of new volunteers.
We look forward to hearing from you soon. If you have any questions, please contact Rachel Woon, Program
Coordinator Operation Smile Singapore at 65-6473 3709 or email her at rachel.woon@operationsmile.org.sg
Best regards,

0720373

Medical Volunteers Department

352 Tanglin Road, #01-05, Tanglin International Building, Singapore 247671

6473 3709 FAX (65) 6473 3710 EMAIL info@operationsmile.org.sg
www.operationsmile.org.sg

PHONE (65)

International Surgery updated June 2010

1

MEDICAL MISSION VOLUNTEER SURGEON APPLICATION

Name:_____________________________ _____________________________ ___________________
(Last)

(First)

(Middle)

Home Phone: (_____)_______________________ Work Phone:(_____)________________________

Cell Phone: (_____)_________________________ Email:_____________________________________

Home Address:_______________________________________________________________________
City:__________________________ State:________ Post Code:____________ Country:___________
Place of Work: _______________________________________________________________________
Work Address: _______________________________________________________________________
City:__________________________ State:________ Post Code:____________ Country:___________

0720373

Preferred Mailing Address (check one):

____Home Address

____Work Address

352 Tanglin Road, #01-05, Tanglin International Building, Singapore 247671

6473 3709 FAX (65) 6473 3710 EMAIL info@operationsmile.org.sg
www.operationsmile.org.sg

PHONE (65)

International Surgery updated June 2010

2

PLEASE CHECK APPROPRIATE SPECIALTIES

Please select from the following specialties ONLY. Check more than one if applicable.

____Plastic Surgeon

____Micro Surgeon

____Burn Surgeon

Please answer the following questions honestly. The well being of children rely on your credibility and
expertise. If you do not have enough experience in these specific areas particularly working with cleft
lips and palates on pediatric patients, you may re-apply at a later time. Your application will be
considered incomplete if any question is left unanswered.
1. How many cleft lips have you done in the past year?
a) How many cleft lips have you done in the past 5 years?

b) How many cleft lips have you done in your surgical career?

Explain.

2. How many cleft palates have you done in the past year?
a) How many cleft palates have you done in the past 5 years?

b) How many cleft palates have you done in you surgical career?

Explain.
3. Would you be comfortable performing surgery at your own table (with little or no supervision) with
good to excellent surgical results? Explain.

4. Do you have any experience working on medical missions?

0720373

_________________________________________________________________________________

352 Tanglin Road, #01-05, Tanglin International Building, Singapore 247671

6473 3709 FAX (65) 6473 3710 EMAIL info@operationsmile.org.sg
www.operationsmile.org.sg

PHONE (65)

International Surgery updated June 2010

3

5. How long does it take for you to perform your standard cleft lip operation?

6. How long does it take you to perform your standard cleft palate operation?

7. What is your experience with burns (be specific)?

_________________________________________________________________________________
a) How many burn cases have you performed in the past year?

b) How many burn cases have you performed in the past five years?

8. What is your experience with hand surgery (be specific)?

a) How many hand surgery cases have you performed in the past year?
_________________________________________________________________________________
b) How many hand surgery cases have you performed in the past five years?
_________________________________________________________________________________
9. Are you experienced and comfortable performing Pharyngoplasties?

CURRENT EXPERIENCE: Please indicate which types of patients/programs you have had
experience with in the last 3-5 years, and describe your current work.
____Pediatrics (0-6 years old)

____Burns

____Youth (7-14 years old)

____Orthopedics

____Adult (over 14 years old)

____Craniofacial

Please briefly describe the nature of your current work:

____________________________________________________________________________________
____________________________________________________________________________________

0720373

____________________________________________________________________________________
352 Tanglin Road, #01-05, Tanglin International Building, Singapore 247671
6473 3709 FAX (65) 6473 3710 EMAIL info@operationsmile.org.sg
www.operationsmile.org.sg

PHONE (65)

International Surgery updated June 2010

4

Specialty Training:
School / Hospital
Cleft Lip
Cleft Palate
Burns
Flaps
Hand Surgery
Microsurgery
Club Foot
Pediatric Ortho
Peds Anesthesia
Other

Dates
to
to
to
to
to
to
to
to
to
to

Degree(s)

Board Certification or equivalent - Certification or membership of an Accrediting Institution for your specialty
Board Certified:
Board Eligible:

YES
YES

Specialty:_________________ Institution:________________________Date:_______
Specialty:_________________ Institution:________________________Date:_______

Have your medical privileges ever been suspended?

YES

NO

If YES, please explain:_________________________________________________________________

____________________________________________________________________________________
Have you ever participated in any overseas medical/healthcare work?

YES

NO

If YES, explain:______________________________________________________________________
___________________________________________________________________________________

Languages spoken and sign language (please indicate level of fluency):__________________________

___________________________________________________________________________________

0720373

___________________________________________________________________________________

352 Tanglin Road, #01-05, Tanglin International Building, Singapore 247671

6473 3709 FAX (65) 6473 3710 EMAIL info@operationsmile.org.sg
www.operationsmile.org.sg

PHONE (65)

International Surgery updated June 2010

5

Are you available on short notice to join a mission team?

Yes with 1 2 weeks notice
Yes with 3 4 weeks notice
No
Short notice availability does not affect the application process but allows Operation Smile to adjust to
the changing circumstances of our mission countries and volunteers.
PASSPORT INFORMATION

Passport #:___________________________________

Passport Type:________________________

Date of Birth:____________________ Place of Birth:________________________________________

Nationality:__________________________________________________________________________
Issuing Authority name and city:_________________________________________________________
Date Issued:_________________________________ Expiration:_______________________________

References
Please provide information for three individuals from within your specialty who can attest to your clinical ability,
professionalism, and ability to work as a part of a team in high-stress situations. One of these references MUST
be the head of the department where you practice. Our Plastic Surgery Specialty Council may contact these
references during the application review.

0720373

Reference #1
Name:________________________________________________
Position: ________________________________________________
Company/Hospital: ________________________________________________
City, State, Country:________________________________________________
Telephone #:________________________________________________
Email: ________________________________________________
For how long did you work closely with this reference? _____ years _____ months
In what capacity did you work with this reference? __________________________________________
____________________________________________________________________________________
Is this reference an Operation Smile volunteer? (circle) YES
NO
352 Tanglin Road, #01-05, Tanglin International Building, Singapore 247671
6473 3709 FAX (65) 6473 3710 EMAIL info@operationsmile.org.sg
www.operationsmile.org.sg

PHONE (65)

International Surgery updated June 2010

6

Reference #2
Name:________________________________________________
Position: ________________________________________________
Company/Hospital: ________________________________________________
City, State, Country:________________________________________________
Telephone #:________________________________________________
Email: ________________________________________________
For how long did you work closely with this reference? _____ years _____ months
In what capacity did you work with this reference? __________________________________________
____________________________________________________________________________________
Is this reference an Operation Smile volunteer? (circle) YES
NO

0720373

Reference #3
Name:________________________________________________
Position: ________________________________________________
Company/Hospital: ________________________________________________
City, State, Country:________________________________________________
Telephone #:________________________________________________
Email: ________________________________________________
For how long did you work closely with this reference? _____ years _____ months
In what capacity did you work with this reference? __________________________________________
____________________________________________________________________________________
Is this reference an Operation Smile volunteer? (circle) YES
NO

352 Tanglin Road, #01-05, Tanglin International Building, Singapore 247671

6473 3709 FAX (65) 6473 3710 EMAIL info@operationsmile.org.sg
www.operationsmile.org.sg

PHONE (65)

International Surgery updated June 2010

7

APPLICATION PROCESS:
Please send this completed application along with:

Current Curriculum Vitae/Resume

Copies of diplomas and degrees
Current copy of Board certification (or equivalent)
Current copies of licensure
Copy of your passport

It is very important that you send all of the above information together with the completed application. If any of
the above information is not in the application packet, the application is considered incomplete. You will be
notified if your application is incomplete.
Completed application packets will be sent to their respective medical specialty council for review at which time
you may be interviewed by telephone or asked to submit additional information. Operation Smile will inform you
of the results of your application.
If an applicant is selected for a mission, all of his/her work will be done on a volunteer basis. Transportation and
lodging are provided by Operation Smile, but each team member will be required to pay a sponsorship fee ($500)
to help defray part of the mission expenses. Mission selection guidelines state that all mission teams are to be
comprised of at least 50 percent experienced Operation Smile team members and the remainder of the team of
new volunteers.

Please send all forms to:

Rachel Woon,
Program Coordinator,
Operation Smile Singapore
352, Tanglin Road, #01-05
Tanglin International Center
Singapore (247671)
Or fax to: 6473 3710

I have read the above and certify that the foregoing is true, correct and complete. I shall promptly
inform Operation Smile if there is any change to the facts herein.

0720373

Signature: ___________________________________

Date:______________________________

352 Tanglin Road, #01-05, Tanglin International Building, Singapore 247671

6473 3709 FAX (65) 6473 3710 EMAIL info@operationsmile.org.sg
www.operationsmile.org.sg

PHONE (65)

International Surgery updated June 2010

8